Human Informed Consent Form

Instructions to the Student Researcher(s): An informed consent/assent/permission form should be developed in

consultation with the Adult Sponsor, Designated Supervisor or Qualified Scientist.
This form is used to provide information to the research participant (or parent/guardian) and to document written informed
consent, minor assent, and/or parental permission.
• When written documentation is required, the researcher keeps the original, signed form.
• Students may use this sample form or may copy ALL elements of it into a new document.

If the form is serving to document parental permission, a copy of any survey or questionnaire must be attached.

Student Researcher(s):
Dandel Oliver S. Prado* Yasvin Pazvic S. Campos Russel Mel D. Cueva Elayssa Nell C. Padilla Marty B. Reyes Savina Stasja F. Soria Jera Ysabelle G. Uy

Title of Project: GASTRON: A Learning Application to improve Sixth-grade Learners’ Knowledge about Parts & Functions of the Digestive System

I am asking for your voluntary participation in my science fair project. Please read the following information about the project.
If you would like to participate, please sign in the appropriate area below.
The purpose of our study is to help sixth-grade learners to improve their knowledge
Purpose of the project:
about the parts and functions of The Digestive System

If you participate, you will be asked to:

Have a mobile device that has minimum system requirements of Android 5.5 and a minimum of 1 GB of storage space

Time required for participation:

maximum of 1 hour and 30 mins
Potential Risks of Study:
There are no potential risks in this study

Benefits:
Better Understanding of the Digestive System topic because of the gamified approach of the application
How confidentiality will be maintained:
Participants will answer a survey regarding their experience with our application. No identifying information will be collected.

If you have any questions about this study, feel free to contact:

Yolly G. Uy
Adult Sponsor/QS/DS: ____________________________________ 09198418730
Phone/email: ____________________

Voluntary Participation:
Participation in this study is completely voluntary. If you decide not to participate there will not be negative consequences.
Please be aware that if you decide to participate, you may stop participating at any time and you may decide not to answer any
specific question.

By signing this form I am attesting that I have read and understand the information above and I freely give my consent/assent
to participate or permission for my child to participate.

Adult Informed Consent or Minor Assent Date Reviewed & Signed:

(mm/dd/yy)

Research Participant Printed Name: Signature:

Parental/Guardian Permission (if applicable) Date Reviewed & Signed:

(mm/dd/yy)

Parent/Guardian Printed Name: Signature:

Page 38 International Rules: Guidelines for Science and Engineering Fairs 2018 – 2019, student.societyforscience.org/intel-isef